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Strengthening Health System Responses to Gender-based Violence in EECA: A resource package
7. Documentation of GBV
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Strengthening Health System Responses to Gender-based Violence in EECA: A resource package
Aim of this module
• To explain why it is necessary to document
GBV
• To provide an overview of the different steps
involved in
– Recording and classifying injuries
– Documenting GBV
– Providing medico-legal services
– Storing patient data
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Strengthening Health System Responses to Gender-based Violence in EECA: A resource package
Outlook
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Importance of documenting GBV
Recording and classifying injuries
How and what should be documented
Forensic examinations
Providing evidence in court
Storage and access to patient records/info
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Strengthening Health System Responses to Gender-based Violence in EECA: A resource package
Importance of documenting GBV
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Strengthening Health System Responses to Gender-based Violence in EECA: A resource package
Uses of documentation
Health professional’s
legal issues
• Professional
obligation to record
details of any
consultation with a
patient
• Notes should reflect
what patient said,
what was seen and
done
• Keep confidential
Patient’s legal issues
For good clinical care
• Medical records can
be used in court as
evidence
• Documenting health
consequences may
help court in decisionmaking and provide
info about
past/present violence
• Lack of coordination
between healthcare
and police/
prosecutors can
cause loss of
evidence
• Documentation can
alert other health care
providers, who may
later attend the
patient, to her
experiences of GBV
and thereby assist in
providing appropriate
follow-up care
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Strengthening Health System Responses to Gender-based Violence in EECA: A resource package
Recording and classifying injuries
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Strengthening Health System Responses to Gender-based Violence in EECA: A resource package
Recording and classifying injuries
• Recording - carefully describe any injuries
– Type, number of injuries, and location using a body map
– In case a survivor does not disclose, note whether the
injuries are compatible with her explanations
• Interpretation involves determining age of an injury,
how it was produced or the amount of force required
to produce the injury (for forensic purposes)
• Without accurate documentation and expert
interpretation, conclusions on how injuries occurred
might be seriously flawed.
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Strengthening Health System Responses to Gender-based Violence in EECA: A resource package
Don’t interpret without training
• Health care professionals who are not
trained in interpretation of injuries should
– document injuries, using standard terminology
as provided in the WHO medico-legal guidelines
for victims of sexual violence (i.e. abrasions,
bruises, lacerations, incisions, stab wounds or
gunshot wounds)
– refer the task of injury interpretation to a
forensic specialist
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Strengthening Health System Responses to Gender-based Violence in EECA: A resource package
How and what should be
documented
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Strengthening Health System Responses to Gender-based Violence in EECA: A resource package
What to document in cases of sexual
violence
Information including:
 demographic information & patient education
 consents obtained
 history (i.e. general medical and gynaecological history)
 an account of the assault
 results of the physical examination
 tests and their results
 treatment plan
 medications given or prescribed
 referrals given
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Strengthening Health System Responses to Gender-based Violence in EECA: A resource package
How to document
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•
•
•
Hand-written notes
Diagrams
Body charts
Photography
– Should be used to
document injuries, but
not replace other
methods of recording
– Important evidence for
criminal proceedings
Checklist for photography
 Consider the patient
 Identification
 Scales
 Orientation
 Chain of custody
 Security
 Sensitivity
H26
H27
H28
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Strengthening Health System Responses to Gender-based Violence in EECA: A resource package
Forensic examinations
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Strengthening Health System Responses to Gender-based Violence in EECA: A resource package
Forensic examination
“Medical examination conducted in the knowledge of the possibility
of judicial proceedings in the future requiring medical opinion”
Principles for specimen collection:
• collect carefully, avoiding contamination
• collect specimens as early as possible (72 hours after
assault, value of evidentiary material decreases)
• label all specimens accurately
• dry all wet specimens
• ensure specimens are secure and tamper proof
• maintain continuity
• document details of all collection/handling procedures
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Strengthening Health System Responses to Gender-based Violence in EECA: A resource package
Providing evidence in court
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Strengthening Health System Responses to Gender-based Violence in EECA: A resource package
be readily available
be familiar with basic
principles, practice of
the legal system, and
obligations
Expectations
of health care
providers
make sound clinical
observations
reliably collect
samples from victims
of crime
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Strengthening Health System Responses to Gender-based Violence in EECA: A resource package
Guiding principles
Writing reports
1. Explain what you were told and
observed.
2. Use precise terminology.
3. Maintain objectivity.
4. Stay within your field of
expertise.
5. Distinguish findings and
opinions.
6. Detail all specimens collected.
7. Only say or write what you
would be prepared to repeat
under oath.
Giving evidence in court
1. Be prepared.
2. Listen carefully.
3. Speak clearly.
4. Use simple and precise language.
5. Stay within your field of
expertise.
6. Separate facts and opinion.
7. Remain impartial.
** Without specific training of medico-legal
aspects of service provision, health
professionals should not offer an
opinion. The court can seek an expert
for interpretation of observations. 16
Strengthening Health System Responses to Gender-based Violence in EECA: A resource package
Storage and access to patient
data
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Strengthening Health System Responses to Gender-based Violence in EECA: A resource package
Storage and access to patient data
Professional, legal
and ethical duty to
maintain and respect
patient
confidentiality and
autonomy.
Records/information
should not be
disclosed to anyone
except those directly
involved in the case
or as required by
local, state and
national laws.
All patient records
should be stored in
a safe place.
Biological evidence
usually needs to be
refrigerated or
frozen; check with
your laboratory.
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